alarm management: electrocardiographic lead management

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Winter 12-18-2015

Alarm Management: Electrocardiographic LeadManagementDale Elaine Dominguez Ms.University of San Francisco, [email protected]

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Running Head: ALARM MANAGEMENT: ELECTROCARDIOGRAPHIC

1

Alarm Management

Electrocardiographic Lead Management

Dale Dominguez, RN, MSNc

University of San Francisco

School of Nursing and Health Professions

ALARM MANAGEMENT: ELECTROCARDIOGRAPHIC 2

Clinical Leadership Theme

The chosen project theme integrates the master's essential of Quality Improvement and

Safety. The identified competency is the process of using researched evidence to create and

coordinate system improvement that will speak to trends in safety and quality (AACN, 2013).

The defined project will be to reduce the number of electrocardiographic (ECG) alarms in the

microsystem by ensuring appropriate ECG lead placement and changing the patient's lead

electrodes daily. My role as the Clinical Nurse Leader (CNL) will be to assess the microsystem

to define the problem, ascertain the workflow of the unit, and identify the barriers and needs in

order to create a project action plan. The action plan will include staff education, surveillance

and auditing for compliance and improvement, and staff rounding to assist with the refreezing

process, as defined in Lewin's process change theory (University of San Francisco, 2015) thus

ensuring that the new process becomes a routine part of the nursing staff's care.

Statement of the Problem

Hospitals today contain numerous pieces of equipment that have alert alarms. These

pieces of equipment produce innumerable alerts, many of which are unnecessary and/or low-

priority. These nonessential alarms cause clinical staff to become desensitized to the alerts. This

desensitization leads to delayed response time and even disabled alarms, posing a safety hazard

to patients. The alerts also disrupt patient sleeping patterns, which contribute to sleep

disturbances that lead to intensive care unit (ICU) delirium. These sleep disturbances lead to

poorer patient outcomes and increased length of stays (LOS). Patient satisfaction rates decrease

with the greater level of environmental noise. Nursing satisfaction is also a factor. Nurses found

the excessive number of alarms interrupted patient care and led staff to distrust the facilities

monitoring systems (Cvach, 2012). Staff timeliness and efficiency will improve as less time is


spent addressing inappropriate alarms. Decreasing alarm alerts will benefit the patient and

clinical staff who care for those patients.

Project Overview

The project's microsystem is a 20-bed adult medical surgical ICU in a 186-bed

hospital in the Sacramento area. The patient population consists of patients with advanced

cardiac, renal, and pulmonary disease, septic shock, gastrointestinal bleeding, and multisystem

failure. The nursing ratio is one nurse to two patients unless the patient meets a criterion that

indicates that one to one care is required. There are no certified nursing assistants or monitor

technologists working in the unit. The charge nurse is usually unencumbered of patients, but is

the lead nurse on the rapid response team, in-house code blue team, and stroke team. Because of

these duties, the charge nurse's role in watching the central monitoring system to assess alarms is

limited. Each nurse is responsible for observing the cardiac monitors for each of their patient's.

The first goal of the project is to have the staff complete an Alarms Management

survey/pre-test to assess the ICU nurse's knowledge about alarm fatigue and appropriate lead

placement (Appendix A). The second goal involves developing a learning module with the

findings from the survey/pre-test, information from an extensive literature search, and

information provided from the DignityHealth's regional Alarm Management Committee. The

learning module will include expanded information about alarm desensitization, appropriate skin

preparation prior to electrode placement, proper lead placement, and daily changing of

electrodes. Included is a post-test to evaluate the nurse's comprehension level of the material and

provide remediation as needed. The objective of the learning module is to have nursing staff

implement these practices into their every day routine. Ninety percent of the ICU staff will be

required to complete the learning module. Goal three will be to collect data to assess compliance

as a result of the intervention. Daily rounds will be conducted to assess appropriate lead


placement, obtain feedback from staff about the project, answer process questions, and reinforce

staff's compliance. Data will be obtained by auditing the patient's electronic medical records

(EMR) to assess documentation confirming daily electrode change. Although the current cardiac

monitoring system is not able to generate a report identifying the specific types of alarms, hand

extracted data will provided basic information about the number of alarms and identify whether

the alarms are high or low alert. Baseline alarm data will be collected for comparison with the

data obtained at the end of project. Data collected from the rounding and EMR auditing will be

posted for staff to view progress and reports will be given to the leadership team and the

hospital's risk manager.

The specific aim for this alarm management project is that by August 1, 2015, 100% of

the nursing staff in the ICU will have properly placed cardiac monitor leads on their patients.

Also, by that date, 90% of the staff will document changing the cardiac monitor electrodes at

least once in a 24-hour period. The aim statement relates to the global aim of the project as

follows: upon full implementation of the project's process, results will indicate that a) patient

safety will increase due to a decrease in alarm fatigue as staff control and manage high-alert

alarms: b) staff efficiency will improve as less time is spent addressing inappropriate alarms; and

c) both patient and staff satisfaction will increase as the frequency of alarms decrease. These

results will ensure better outcomes for the ICU patients.

Rationale

Alarm management is a patient safety issue that has become more prominent in recent

years. The Emergency Care Research Institute (ECRI) has named alarm hazards as the number

one health technology hazard for 2015 (Top 10 Health Technology, 2014). The need for alarm

management to decrease those hazards is crucial. Observation of the microsystem has

demonstrated a need for alarm management as an assessment of the microsystem noted delays,


including non-response times from nursing staff to the myriad of alarms that sound. The majority

of the alarms were low level, yet no staff attempted to customize the alarms or change electrode

pads. On two different occasions patients who had a potentially lethal rhythm (one had a short

runs of ventricular tachycardia and one a bradycardia) that were unnoticed for a period of time.

Staff finally recognized both of the patients’ rhythms and treatments were administered. In

addition, during my observation of the ICU, a patient became disconnected from their ventilator

and seeing no response from staff members, I quickly entered the room and placed the patient

back on the ventilator. Results of the survey/pre-test revealed that when asked how disruptive

false clinical alarms are to the daily workflow, 1 being not disruptive and 10 being constantly

disruptive, 85% of the staff rated the disruption at a 5 or greater (Appendix B). Sixty percent of

the same group of nurses also related that in the past year they had witnessed a delay in response

to an urgent patient situation as a result of excessive false clinical alarms (Appendix C).

Assessment of the microsystem clearly identified a patient safety risk.

Other analyses that support the project are the results of a hospital gap analysis, that was

a modified version of the a gap analysis done the DignityHealth's regional Alarm Management

Committee (Appendix D) and a Fishbone diagram (Appendix E) that indicate a lack of alarm

management poses a significant increase in the possibility of sentinel events. Completion of a

process SWOT analysis (Appendix F) identified areas of needed improvement that support the

implementation of the project.

A literature review also revealed the need for alarm management. The Joint Commission

released a Sentinel Event Report identified that between 2009 and 2012 there were 98 reported

alarm related events (The Joint Commission, 2013). Also in 2013, The American Association of

Critical Care Nurses (AACN) released a practice alert addressing the need for alarm

management in ICUs (Sandelbach & Jepsen,, 2013).


Justification for the project also occurred as a cost analysis was done. Total cost of the

program implementation is approximated at $5,620 (Appendix G). The benefits include

decreased LOS as a result of sleep disturbances that may lead to ICU delirium. According to

Thomason, Shintani, Peterson, Pun, Jackson & Ely (2005), delirium can develop in up to 48% of

the ICU patients, increasing LOS by one day.

Qualitative benefits include increased patient satisfaction as the result of less disruptive

noise during the patient's stay. Increased patient satisfaction is reflected in The Hospital

Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and effects

reimbursement rates. Nurse satisfaction increases in response to a decrease in alarm alerts.

Lastly, the implementation of an Alarm Alert Management Program, which includes

ECG lead placement, will meet The Joint Commission's National Patient Safety Goal (NPSG)

implementation requirement (The Joint Commission, 2015). Meeting this requirement will help

insure reimbursement by Medicare and Medicaid. Evaluating both the safety risk to patients and

a potential cost savings supports the rational for the project

Methodology

Lewin's Change Module will be used for my project. Unfreezing, which is the first step of

the change module, brings the issue to the attention of the employees and looks for barriers and

problems that may interfere with implementation. Unfreezing was demonstrated as one-on-one

time was spent with the ICU nurses, explaining why the program was important, how important

their contribution would be, and how the process would work. During this time staff were given

information about alarm fatigue and were told about the survey/pre-test that would be used to get

their feedback about alarm fatigue, identify any possible barriers, and assess their baseline

knowledge on the subject. Actions, or the moving step of the change module, occurred as goals

and objectives were developed and an education module for the process was developed. This


education module was based on the survey's findings, recommendations from the AACN, and

information provided from the hospital's regions informational huddle on alarm management.

After staff completion of the module, unit rounding and auditing of patient EMRs were done.

Progress reports were provided to staff and leadership. The last step of Lewin's change module,

Refreezing, was demonstrated in the project when the new change became part of routine

activities of the nursing staff. Continued monitoring was done to assist in maintaining

compliance, get feedback from staff regarding barriers, to promote the project, and to give

updates about the progress of the project to leadership for their continued support.

Data collected included results from daily rounding on each patient to evaluate if ECG

leads were appropriately placed. Auditing of each patient's medical record was done to verify,

through documentation, that the patient's electrodes were being changed daily and alarm data

from the cardiac monitoring system was gathered and compared to the baseline data. This data

will assist in evaluating the effectiveness of the interventions.

The desired goal will be reached if, by the end of the project, a) rounding audits show

appropriate ECG leads placement on 100% of the patients, b) 90% of the charts audited will have

documentation as to daily patient electrode change, and c) if baseline data can be obtained, there

will be a 5% decrease in alarm alerts.

Data Source/Literature Review

The project focuses on the nursing staff's ability to successfully implement the process of

appropriate ECG lead placement and daily electrode change. This success is measured by patient

rounding; chart audits, and analyzing alarm alert data that will lead to the project's ultimate goal

of decreasing the number of false alarm alerts. The benefits will provide a safer patient

environment. The literature review revealed several sources that confirmed the need for alarm

management as a means to providing a safe patient environment. Phillips, Ainsworth, Canella,


Crumley, Ellstrom, Fleischman, Moffitt, Radovich, & White (2014) confirmed the need for

alarm management and six out of the last eight years the ECRI has listed alarm safety as the

number one technology safety hazard. Using the steps of define, measure, analyze, design, and

verify from the Six Sigma Process, the authors were able to clearly define the issue and develop

a plan of action to address the major issues.

The ECRI (2014), in its annual report, identified alarm safety as the number one potential

source of health technology hazard. The danger occurs when clinical staff are not advised when a

valid alarm condition develops, or when they are being exposed to an excessive number of

alarms, most of which are clinically insignificant. The report noted that inadequate alarm

configuration was the major contributing factor to the danger. Policies for alarm configuration

should address selecting appropriate alarm limits based on the patient, identifying which alarms

can be disabled, and setting appropriate default alarm priority levels.

In a practice alert published by AACN, it was noted that 80% to 99% of ECG monitor

alarms are false or do not required an immediate response (Sendelbach & Jepsen, 2013). The

alert recommended proper skin preparation prior to placing the ECG electrodes to decrease

signal noise and skin impedance. This preparation enhances conductivity, thus decreasing the

number of false alarms. Skin should be washed with soap and water or wiped with a rough

washcloth or gauze and excess hair should be clipped (Sendelbach & Jepsen, 2013). Daily

electrode change was also recommended.

The high rates of false alarms contribute to a noted delay in response time by nursing

staff. The staff is aware that a large number of alarms do not require their immediate attention, so

the urgency to respond is lessened. Edworthy (2012) noted that many times staff response rates

match their understanding of the accuracy of the alarm. If their perception of the accuracy of the

alarm is low, perhaps 10%, their response to the alert will also be close to 10%.


The Joint Commission’s Sentinel Event database includes reports of 98 alarm-related

events between January 2009 and June 2012 (The Joint Commission, 2013). Of the events, 13

resulted in permanent loss of function and 80 resulted in death. More than 90% of the reported

events occurred in hospitals. The greatest number of those events occurred in telemetry or ICUs

that were found to have staff training deficiencies on the proper use and function of the

equipment. The Joint Commission strongly believes that alarm-related events are vastly

underreported.

An article by Konkani, Oakley, & Bauld, (2012) provided a study of journal articles and review articles to identify best practices used to decrease the number of nuisance clinical alarms.

Results indicated that the practice that reduced the most false alarms was customizing default

ECG alarms. Another factor that reduced alarms was the standardization of policies and

protocols related to clinical alarm management. The article also concluded that more studies are required to assess the effect of alarm differentiable features and the design of smart alarms. Alarm alerts also increase LOS due to sleep disturbances that may lead to ICU delirium.

In a study of five ICUs done in 2013, environmental noise caused between 11% and 17% of

arousal and awakening episodes in patients (Darbyshire & Young, 2013). According to

Thomason, Shintani, Peterson, Pun, Jackson & Ely (2005), delirium can develop in up to 48% of

the ICU patients when environmental noise is a contributing factor. This delirium may increase

LOS by one full day.

Another component of alarm management is the impact of patient satisfaction scores on

which the Centers for Medicaid and Medicare Services (CMS) are basing a portion of their

reimbursement to hospitals. HCAHPS surveys are used to measure patients’ perceptions of their

experiences in the hospital. Fifty-three percent of the respondents at the ECRI Institute’s 2013

alarm safety web conference identified that alarm issues have impacted their facility’s patient


satisfaction scores (Vanderveen, 2014). The provided literature strongly supports the identified

need for the alarm management project.

Timeline

A microsystem assessment occurred in the first week of June, which included a unit

observation period, a gap analysis (Appendix D), and the completion of a root cause analysis

fishbone diagram (Appendix E). The next week a survey/pre-test (Appendix A) was developed

using the results of the microsystem assessment and a literature search. The following two weeks

the survey/pre-test was distributed to staff completed and returned. An analysis (Appendix F) of

the survey/pre-test was done during the next week in preparation for developing an education

module. During the first part of July, development of an education plan (Appendix I) occurred

and in mid-July the education module was distributed and collect once completed. The last week

of July and the first week of August assessment of compliance (Appendix K) to the process

change was done. In mid August the results were added to the final paper and PowerPoint

presentation. See Appendix H for the completed Gantt chart showing the project timeline.

Expected Results

Expectations were that the number of alarms would decrease after implementation of the

process. Unfortunately, the cardiac monitoring system currently used is not readily able to

generate clear reports on the number and type of alarms. Limited information will have to be

manually extracted from the system. Because gathering the data is such a laborious task,

availability to post process information was limited. Another expectation was that although

research has shown that alarms can decrease up to 46% in the ICU (Cvach, 2012) with daily

changing of electrode pads, the percentage decreased would be less because the survey/pre-test

indicated that the majority of the staff were aware of daily electrode changes and some were


currently changing the leads. Indications of the knowledge of daily electrode changes verses

daily practice will be evident in the EMR audits that will occur post intervention.

It is expected that appropriate lead placement will increase. The survey/pre-test showed

that about 55% of the staff was placing the brown (V1) lead in the incorrect position. Placing the

brown lead in the correct position may not lead to a large decrease in alarm alerts, but the

accuracy of the displayed rhythm should increase.

Another expectation is that this project would increase the staff's general knowledge

about alarm management. This project is just the first of many other processes involving alarm

management that will be incorporated in the ICU. The baseline knowledge and the understanding

of urgency of change will assist with the next alarm management change process. Customizing

the alarm limits will be the next process implemented. The hospital and its sister hospital in the

Sacramento area are in the process of purchasing a middleware product that will assist in

obtaining more accurate alarm alert data. The Medical Safety Device Committee hopes that the

middleware will be installed by the time the alarm customization process begins. Although the

middleware may be available, the monitor itself is a less sophisticated model so there will be

limitations on what alarms can be customized.

Nursing Relevance

One of the roles of the CNL is to help to ensure a safe environment for the patient.

Promotion of an alarm management program will assist in providing that safe environment. The

process of skin preparation prior to electrode placement, placing the ECG leads in the correct

position, daily electrode changes, and customizing alarms must be incorporated into the

clinicians daily routine. These steps will assist in decreasing alarm alerts, thus assisting in

decreasing staff alarm fatigue. In addition, it will allow the staff to spend more time with their

patients and increase both patient and nursing satisfaction.


The Joint Commission has added alarm management as a NPSG (The Joint Commission,

2015) and is requiring care facilities to implement a Medical Device Alarm Management

Program. Compliance to regulatory bodies is a top priority for healthcare institutions and this

project will assist in that goal. This is especially important as further alarm management

processes will occur in the unit and this first project will provide staff preparation for projects to

come.

Evaluation

The aim of the project was to reduce the number of (ECG) alarms in the microsystem by

ensuring appropriate ECG lead placement and the daily changing of the patient's lead electrodes.

With the implementation of these processes the goal is a 5% reduction in alarm rates in a 24-hour

period. The microsystem in which my project was implemented is a 20 bed adult medical ICU in

a 186-bed community hospital. The nursing staff is comprised of both experienced and novice

nurses. The unit's registered nurse (RN) to patient ratio is one-to-two unless a patient meets a set

acuity criteria that indicates that one-nurse-to-one-patient care is required to provide appropriate

care to the patient. The unit does not utilize licensed vocational nurses (LVN), nursing assistants

(NA), or monitor technicians in the care of the patients. The RN staff is responsible for the

operation and surveillance of all of the cardiac monitoring equipment. Because the staff are not

able to view the cardiac monitors at all times, they rely on alarm alerts to notify them of needed

interventions to the patient. As previously noted, 80% to 99% of ECG monitor alarms are false

or do not require an immediate response (Sendelbach & Jepsen, 2013). Because of the high

number of false alerts, staff responses to these alerts can be delayed thus causing a possible delay

in response to an event that requires immediate attention.

The project began with the distribution of a survey/pre-test to the nursing staff for the

purpose of assessing the staff's baseline knowledge about alarm fatigue and its management.


Knowledge of the proposed interventions was also assessed. Distribution occurred on a one-to-

one basis providing an opportunity to speak to the staff about the importance of the project and

how its implementation would provide a safer environment for the patient population. Emphasis

was also placed on how their contribution to the project could make a significant difference to

the quality of care that was provided by the ICU. Upon returning the survey/pre-test, a sweet

treat was rewarded to the nurse. The expectation of the survey/pre-test was not that the staff

would produce a high score, but to create a sense of urgency about the project. In response to the

survey, there were occasions when staff would approach me and inquire about answers to

specific questions, thus allowing me to begin a short discussion about the question and other

pertinent items regarding alarm management. Also, during the roll out of the survey/pretest two

emails were sent to staff and flyers were hung in the staff bathroom reminding the nurses to

complete and return the survey.

After a two-week period, 80% of the surveys were returned. Assessment of the surveys

indicated that few of the staff knew the high rate of false alerts that occurred or how significantly

the number of alert alarms would decrease with the simple change of electrodes on a daily bases.

It was also quite surprising to discover the number of staff who was placing the patient's V lead

in the incorrect position. Most staff answered correctly that electrodes were to be changed daily,

but it is unclear how many actually subscribed to this practice. Results of the survey contributed

to the development of the actual education material.

After analyzing the results of the survey/pre-test, deciding what information was most

important from my literature reviews, and considering the required corporate information on

alarm management, a learning material was formulated (Appendix I). A short quiz to assess the

staff's comprehension of the learning material also was developed (Appendix J). The education

material and quiz were distributed emphasizing the importance of their completion. Some


questions from the survey/pre-test were repeated on the quiz to emphasize the importance of the

content. Staff was paid one half hour of mandatory education time for the completion of the quiz.

Ninety-four percent of the staff completed and returned the quiz. Very few completed the quiz

with less then 100% correct.

Upon completion of the education process an eight-day audit was done. The auditing

consisted of daily rounding of each patient in the unit to check for appropriate lead placement

and to speak to the nurse caring for the patient if placement was incorrect or to get general

feedback on the process. Auditing of each patient's chart was done to confirm that daily electrode

change had occurred. Lastly, using data from the central monitoring, the number of bed alarm

and yellow alert alarms that fired in a 24-hour period were tallied. Bed alarms trigger as a result

of equipment malfunction or disconnection or as a result of poor signal quality. Yellow alarms

trigger when vital signs are identified as outside preset vital sign limits (Koninklijke, 2006).

Baseline data indicated that in 24 hours a total of 1,311 alarms alerted. These alerts included 443

yellow alerts, 868 bed alert alarms, and two red alert alarms. Red alert alarms indicate a

potentially life threatening condition but were not in included in the daily alarm tally as they did

not add significantly to the number of alerts fired in a 24 hour period. Upon completion of the

auditing process, data showed appropriate lead placement was at 100% and documentation of

electrode change every 24 hours was at 50%. Tallied alarm alerts decreased by 6% for bed

alarms and 3.2% for yellow alarms. Results of the auditing and signs recognizing staff members

who documented a lead change were posted (Appendix K).

Sustainability Plan

The sustainability plan for this project has several aspects. Excellence in care is a core

value for the corporation. Decreasing alarm alerts to provide a safer environment is just one

aspect of providing excellent care. Education about alarm fatigue and the importance of ECG


lead management to decrease the number of alarms has been shared with the staff of the

hospital's emergency department (ED). As the educator for the ICU and the ED, re-education on

the process and its importance will on held at the annual-unit specific skills days. Also, as the

educator, surveillance for compliance can be incorporated into audits that are currently being

performed on other important initiatives. Information from this project has already been shared

with the educators of the medical/surgical department, surgical services department, and the

family birth/neonatal intensive care unit. Unit specific versions of the information has been

developed and distributed to staff on those units. Plans to reinforce education about alarm

management, which will include the information from this project, will be done at the annual

nursing skills days. Lastly, because this project will be connected to a larger alarm management

project in response to The Joint Commission NPSG mandate, it will continue to receive support

from all levels of management.

Conclusion

The goal of 100% correct lead placement was met. Electrode change every 24 hours

scored at 50% that did not meet the 90% goal (Appendix L). The total number of alarms

decreased by 4.6% and did not meet the goal set at 5% (Appendix M). Although the project

proceeded with relatively few setbacks, lessons were learned. First, it was assumed that all staff

had basic knowledge about appropriate lead placement. That was not the case and although the

education material included information about proper placement of the ECG leads, 100%

compliance for placement did not occur until later in the audit period.

Next, it was noted that there was not a specific place in the EMR for the staff to chart

when they changed electrodes. The section of the record that staff documents baths would prove

to be an ideal area to document. Because there is no specific area to document the electrode

change, staff is forced to navigate to the event section of the record and free text the information.


A mock up proposal has been submitted to the clinical informaticist that will be presented at the

regional Cerner design committee meeting (Appendix N).

Another lesson identified was that there were times no electrodes were changed because

some staff did not bathe the patient on a daily basis or the patient was too critically ill to bathe.

To address the issue, staff members were consulted. Unfortunately, the staff was divided because

some staff wished to designate a shift responsible for the electrode change and others preferred

to keep it at the time the patient was bathed. Because the compliance for the electrode change

was noted to be highest during the time of the patient's bath, it was decided that that would be the

most appropriate time to it do the change. Patients with LOS less then 24 hours were excluded

from the electrode change audit.

The next lesson came in the form of issues with collecting data on the number of alert

alarms that occurred in a 24-hour period. The monitored system used in the ICU is an older

generation system that does not generate alarm reports. To gather data, the auditor is required to

open each patient window at the central monitor and print a sheet indicating the number of

alarms. The report shows alarms divided into red, yellow, and bed alerts. No specific information

is given about the individual alert. More in-depth information as to what type of red, yellow, or

bed alarm alert can be retrieved from the actual bedside monitor. Unfortunately the waveform of

the alert is not available to confirm the accuracy of the alert. Gathering the number of alarm

alerts proved to tedious.

Lastly, a positive lesson learned was that the staff is very interested in the project. They

frequently ask questions about its progress and are eager to learn more about the next phase of

the alarm management project. Text messages and emails have been sent from staff with

suggestions to consider improving aspects of the project.


My work on this project has been rewarding because I have learned much about the

subject matter and now have a strong start for the next phase of alarm management program.

Working through the project has confirmed that, as a CNL, working closely with the staff is the

key to a successful program. Communication between the other disciplines, such as leadership,

physicians, biomedical staff, and the risk management person was crucial in forming a strong

team. My overall takeaway from the project was that CNLs assist the microsystem to navigate a

complex healthcare system. They are catalysts for change. This change contributes to cost

containment, better outcomes for the patient, increased staff satisfaction, and the promotion of

nursing as a profession.


References

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aami/files/production/public/FileDownloads/BIT/JA_alarm_fatigue.pdfEmergencyCare

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Radovich, P., White, A. (2014, June). Alarm fatigue: Strategies to safely manage clinical


alarms and prevent alarm fatigue. The National Association of Clinical Nurse Specialists.

Retrieved from http://www.nacns.org/docs/NACNSFatigueToolkit.pdf

Sendelbach, S., & Jepsen, S. (2013, May). AACN practice alert: Alarm management. American

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http://www.aacn.org/wd/practice/docs/practicealerts/alarm-management-practice-

alert.pdf

State of California Office of Statewide Health Planning & Development. (2014). Hospital

chargemasters and charges for 25 common outpatient procedures. Retrieved from

http://www.oshpd.ca.gov/Chargemaster/

The Joint Commission. (2013, April). Medical device alarm safety in hospitals. Retrieved from

http://www.jointcommission.org/assets/1/18/sea_50_alarms_4_5_13_final1.pdf

The Joint Commission. (2015, January). National Patient Safety Goals Effective January 1,

2015.Retrieved from http://www.jointcommission.org/asset/1/6/2015_NPSG_HAP.pdf

Thomason, J. W., Shintani, A., Peterson, J. F., Pun, B. T., Jackson, J. C., Ely, E. W. (2005).

Intensive care unit delirium in an independent predictor of longer hospital stay: A

prospective analysis of 261 non-vented patients. Critical Care, 9(4), 375-381.

Retrieved from http://www.ccforum.com/content/9/4/r375

University of San Francisco. (2015). N651: CNL role synthesis: Module 5: Change

management. Retrieved from

https://usfca.instructure.com/courses/1552955/pages/module-5-introduction-and

readings?module_item_id=16196993


Vanderveen, T. (2014, November-December). Alarm management: First things first.

Using reliable data to eliminate unnecessary alarms. Patient Safety & Quality Health,

11(6), 38-45. Retrieved from http://psqh.com/november-december-2014/alarm-

management-first-things-first


Appendix A

Alarm Management Survey/Pre-test Name__________________

1) How disruptive are false clinical alarms to your daily workflow? (1 = not disruptive at all, 10 constantly disruptive). 1 2 3 4 5 6 7 8 9 10 2) In the past year, have you witnessed a delay in response to an urgent patient situation due to excessive false clinical alarms. True False 3) Alarm desensitization or fatigue develops when a person is exposed to an excessive number of alarm alerts. True False 4) Alarm Fatigue can lead to a) A delay in response to an alarm alert b) The nurse's ability to distinguish high and low alert alarms c) The nurse disabling the alarm alert d) a and c 5) Up to what percentage of electrocardiographic (ECG) monitor alarms are false or clinically insignificant. a) 80% - 99% b) 65% -75% c) 50% - 60% d) 45% - 53%


Appendix A

Alarm Management Survey/Pretest Page 2

6) Prior to placing electrodes on the patient, skin preparation would include all except a) Using mild soap and water to clean the skin's surface b) Using alcohol pads to clear the skin's surface c) Clipping excess hair from the electrode site d) Using gentle abrasion to skin where the electrode is to be placed

7) Electrodes should be placed directly over a bony prominence for stability. True False 8) When applying ECG leads, the brown (V1) lead is placed a) Left of the sternal border at the 4th intercostal space (ICS) b) Right of the sternal border at the 4th intercostal space (ICS) c) Left of the sternal border at the 5th intercostal space (ICS) d) Right of the sternal border at the 5th intercostal space (ICS) 9) How often is it recommended that ECG pads be changed a) Once a day b) Every 2 days c) Every 3 days d) Only as needed 10) Changing electrodes daily may decrease false alarms by a) 25 % b) 37% c) 45% d) 46%

d) 46% 11) Your patient ECG monitor is alarming every 5 to 10 minutes for rhythm pauses > 4 seconds. The patient has identified pauses of greater than 6 seconds, is stable, and current treatment is not required. Is customizing the alarm parameters to decrease nuisance alarm considered appropriate. True False

ALARM MANAGEMENT: ELECTROCARDIOGRAPHIC

1 12

1

0

5

10

15

20

1 2 3 4

Disruptive Alarm Survey Question

Nu

mb

er

of

Nu

rs

es


Appendix B

3

5

2

10

5

10

5 6 7 8 9 10

Disruptive Alarm Survey Question

Disruption Scale

23


Response to an Urgent Situation

60%


Response to an Urgent Situation

Have not witnesses a delay in

response

Have witnessed a delay in

response

40%

Appendix C

24

Have not witnesses a delay in

Have witnessed a delay in


Appendix D

Joint Commission Sentinel Event

Alert Gap Analysis

Joint Commission Recommendation Current

Practice

Significant

Gap?

Actions Taken

by hospital 1. Leadership ensures that there is a process for

safe alarm management and response in high-

risk areas (as identified by the organization).

Clinical alarm policy

developed

Yes No X Formation of a

monthly

performance

improvement

team "Improving

Alarm Safety"

2. Prepare an inventory of alarm equipment

devices used in high-risk areas and for high-risk

clinical conditions, and identify the default alarm

settings and the limits appropriate for each care

area

Areas defined as

high risk areas: ED,

ICU, Telemetry, OR,

PACU, FBC

High-risk clinical

conditions

identified: i.e. ECG

monitoring for

VTach, VFib,

Tachycardias; Fetal

monitors;

Ventilator; Bipap;

Arterial line; Bed

alarms

Yes X No (In Process) Bio

Med provided a

list of life safety

alarm-equipped

medical devices.

The committee

will develop a

comprehensive

grid that identifies

all alarm-

equipped medical

devices, alarm

types, priority

status, alarm

setting

parameters,

warning signs

etc.

3. Establish guidelines for tailoring alarm

settings for individual patients. The guidelines

should address situations when limits can be

modified to minimize alarm signals and the

extent to which alarms can be modified to on;

include identification of situations when alarm

signals are not clinically necessary.

Clinical Alarm

policy "High risk

alarms must not be

turned off/silenced

unless an RN is at

bedside providing

direct care to the

patient.

Majority of current

alarms are set for

default settings and

not individual

patients

Yes X No (By August 2015)

The committee

will develop a

comprehensive


all alarm-

equipment

medical devices,

alarm types,

priority status,

alarm settings,

parameters,

warning signs, etc.


Appendix D

Joint Commission Sentinel Event Alert Gap Analysis

Page 2


Practice

Significant

Gap?

Actions Taken

by hospital

4. Inspect, check and maintain alarm-equipped

devices to provide for accurate and appropriate

alarm settings, proper operation, and

detectability. Base on the frequency of these

activities on criteria such as manufactures

recommendations, risk levels and current

experience

Biomed inspections

based on

manufacturer

recommendations

Yes X No (To follow

implementation of

tailoring grid)

Audit units to

check default

settings based on

manufacturer

recommendations

5. Provide all members of the clinical care team

(as defined by the organization), with training

on organization's process for safe-alarm

management and response in high-risk areas (as

defined by the organization), and on the safe use

of the alarmed medical device on which they

rely.

Provide ongoing training on new alarmed

medical devices and updates to alarmed medical

devices, and ensure that new members of the

clinical care team receive training on the

alarmed medical devices on which they rely

Unit specific

orientation/training

Skills Day -

review/competency.

Unit specific

orientation

checklist.

Yes X No The clinical

educators will

develop

education/training

materials and

distribute as we

review each

alarm-equipped

medical device

and determine

which equipment

needs ongoing

annual review at

Skills Days

6. To help reduce nuisance alarm signals, change

single-use sensors (Ex: ECG leads), according

manufacturers recommendations, unless

contraindicated

Yes X No (In process) The

committee will be

developing a

comprehensive


all alarm equipped

medical devices,

alarm types,

priority status,

alarm settings,

parameters,

warning signs, etc.


Appendix D

Joint Commission Sentinel Event Alert Gap Analysis

Page 3


Practice

Significant

Gap?

Actions Taken

by hospital

7. Establish a cross-disciplinary team

that includes representation from clinical

engineering, information technology, and risk

management, to address alarm safety and the

potential impact of alarm fatigue in all patient

care areas

� Establish a process for continual

improvement and constant optimizing of alarm

system policies and configurations

� Review trends and patterns in alarm-related

events to identify opportunites for improving

alarm use

� Implement an alarm system management

policy, including the periodic review of alarm

coverage processes and systems, and the

development of realistic, implementable

strategies to address vulnerabilities

Yes No X Formation of a

monthly

performance

improvement

team "Improving

Alarm Safety.

Multidisciplinary

team includes:

CNO, Risk

Manager, Quality

Director, Nursing

Directors, Clinical

Informaticist, Bio

Med, Safety officer,

front-line staff,

and VPMA, when

warranted.


Appendix E

EQUIPMENT

MATERIAL PEOPLE

RootCauseAnalysisFishbone

Graph

Desensi za onto

alarms

Stafflackof

knowledgeonlead

placement

Central

Supplynotstocking

electrodestopar

levels

Costofaddi onal

electrodes

Limitedalarm

customiza onability

Limitedreplacement

equipment

LooseLeada achment

toelectrode

NoStandardProcedures

Outlined

Addi onal

Documenta on

METHODS

Stafflackof

knowledgeto

policy

Competency/Trainingon

Alarmcustomiza on

Limiteddatarepor ng

systemCompliancewithbasiclead

placementandelectrodechange


Appendix F

SWOT ANALYSIS

STRENGTHS WEAKNESSES

Need for project confirmed through Lack of staff knowledge on subject

direct observation matter

Need for project confirmed though Barriers to change process from staff

staff survey

Support from leadership for a Joint

Commission mandated project

Available resources

Better patient outcome through safety

OPPORTUNITIES THREATS

Developed baseline knowledge from Outdated monitoring equipment

project will allow for easier transition

for future alarm-management projects Possible loss of long-term support

from leadership

Project process can be shared with

other high-risk departments in the

hospital


Appendix G

Costs

Regional Meetings - Project hospital staff (3 hours x $70.00 x 5 people) = $1,050.00 Meeting Philips Representative- (3 hours x $70.00) =$210.00 Meeting with hospital risk manager (2 hour x $70.00 x 2 people) = $280.00 Developing, distributing, grading, evaluating educational material (12 hours x $70.00) = $910.00 Education hours for staff (70 x .5 x $60.00) = $2,100.00 Rounding and auditing patient's EMR for compliance - (15 hours x $70.00)=$1,050.00 25% increase in electrode use (20/day x .89 cents) = $18.00/day Supplies - $20.00

Benefits 1) Decreased length of stays due to fewer sleep disturbances that can lead to ICU delirium. In a study of five ICUs done in 2013, environmental noise caused between 11% and 17% of arousals and awakening episodes in patients (Darbyshire & Young, 2013). According to Thomason, Shintani, Peterson, Pun, Jackson & Ely (2005), delirium can develop in up to 48% of the ICU patients, increasing length of stays by one day. Average number of patients per day in the ICU: 14 Possible patients with delirium: 7 (48%) Cost per day in ICU: $10,008.00 (Chargemaster, 2014) $10,008.00 x 7 patients - up to $73,576: Although only a percentage of alarm noise contributes to this amount, it presence is significant. 2) Increased response time to alarms as a result of decreased staff alarm fatigue, thus promoting a safe patient environment. Exact benefit data is not available but The Joint Commission reported 98 alarm related events between January 2009 and June 2012 in their Sentinel Event Alert publication (The Joint Commission, 2013). The calculated benefit Total Cost = $5,620.00 + cost of electrodes Total benefit - An exact amount cannot be calculated, but the total cost of the project is less than one extra day in the ICU for a patient with delirium.


Appendix H

ProjectGanttChart

MicrosystemAssessment

Survey/PretestDevelopment

SurveyDistributionandCollection

Survey/PretestAnalysis

EducationDevelopment

EducationDistributionandCollection

PostInterventionDataCollection

FinalAnalysis

June July August


Appendix I

Alarm Management Module

What is alarm fatigue? Alarm fatigue develops when a person is exposed to an excessive number of alarms. The excess of alarms can lead to sensory overload that can lead to alarm desensitization. How dangerous is alarm fatigue? Over a recent four-year period, the FDA received more than 500 reports of patient deaths related to alarm systems on monitoring devices. The Emergency Care Research Institute (ECRI) identified alarm hazards as number one on their top 10 health technology hazards for 2015. When asked to rate how disruptive false clinical alarms were to their daily workflow, 1 being not disruptive and 10 being constantly disruptive, 85% of the staff the nurses in the Intensive Care Unit at Methodist Hospital rated the disruption at a 5 or higher. Sixty percent of this same group of nurses also related that in the past year they had witnessed a delay in response to an urgent patient situation due to excessive false clinical alarms. Who thinks that alarm fatigue and alarm management is important? In 2014 the Joint Commission added a new National Patient Safety Goal that addressed reducing harm associated with clinical alarm systems. Elements of the goal include: � Requiring hospitals to establish alarm safety as a priority �Identifying the most important alarm signals to manage �Establishing policies and procedures for managing alarms �Educating staff about the purpose and proper operation of alarm systems The DignityHealth hospitals in the greater Sacramento area have currently: �Established alarm safety as a priority �Identified the most important signals to manage (Physiologic monitors; pulse oximetry; end tidal CO2; TCM; ventilators; BiPap; hemodialysis -(see policy for complete list) � Developed a Medical Device Alarm Safety policy and procedure � Developed a process of educating staff about the purpose and proper operation of alarm systems What are high-risk areas that require alarm management? ED, ICU, L&D, monitored units, operative and procedure areas, and PACU



What are some basic interventions that can decrease nuisance alarm alerts? Some basic interventions that can decrease the number of nuisance alarms are proper skin preparation prior to electrode placement, appropriate lead placement, and daily electrode pad changes Why is skin preparation before placing electrodes so important? To prepare the skin for electrode placement, dry, deadalong with any natural oils and dirt that impede electrical flow and quality. How should skin preparation be done? 1) Clip hair from electrode site if necessary2) Clean the area with soap and water3) Dry area thoroughly What is the proper placement method for 1) For the patient's comfort, attach the lead wire to the electrode before applying the electrode2) To minimize artifact and maxi areas. 3) Press around the edge of the electrode to apply. Do not press directly on the center of the electrode as it may spread the gel out and create air Where is the proper ECG lead placement?

Ensure the brown precordial lead is placed to the right of the sternal border at the 4th intercostal space


Appendix I


Page 2

What are some basic interventions that can decrease nuisance alarm alerts?

Some basic interventions that can decrease the number of nuisance alarms are proper skin preparation prior to electrode placement, appropriate lead placement, and daily electrode pad changes.

Why is skin preparation before placing electrodes so important?

To prepare the skin for electrode placement, dry, dead epidermal layers of skin must be removed, natural oils and dirt that impede electrical flow and creates a resistance to signal

How should skin preparation be done?

1) Clip hair from electrode site if necessary 2) Clean the area with soap and water or use gentle abrasion with a 4 X 4 gauze pad

method for electrodes?

1) For the patient's comfort, attach the lead wire to the electrode before applying the electrode2) To minimize artifact and maximize the ECG signal strength, avoid major muscle and bony

3) Press around the edge of the electrode to apply. Do not press directly on the center of the electrode as it may spread the gel out and create air pockets that contribute to arti

placement?


33

of skin must be removed, a resistance to signal

4 X 4 gauze pad

1) For the patient's comfort, attach the lead wire to the electrode before applying the electrode. mize the ECG signal strength, avoid major muscle and bony

3) Press around the edge of the electrode to apply. Do not press directly on the center of the to artifact readings.



Appendix I

Alarm Management Module Page 3

Why should electrode pads be changed daily? Changing electrode pads prevents pad dryness and poor conductivity. Nuisance bed alarms are decreased because new leads adhere to the skin better. When is the best time to change the electrodes? Electrodes are usually changed at the time the patient is bathed, but can be changed at any time and PRN. Do I have to chart when I change the electrodes? Yes, you will need to chart your electrode change in the events box in the I-view Flowsheet to monitor compliance.


Appendix J

Alarm Management Module Quiz

Name__________________ 1) Alarm desensitization or fatigue develops when a person is exposed to an excessive number of alarm alerts True False 2) Up to what percentage of ECG monitor alarms are false or clinically insignificant. a) 80% - 99% b) 65% -75% c) 50% - 60% d) 45% - 53% 3) Elements of the Joint Commission new 2014 NPSG include a) Requiring hospitals to establish alarm safety as a priority b) Identifying the most important alarm signals to manage c) Establish policies and procedures for managing alarms d) Educating staff about the purpose and proper operation of alarm systems e) All except d f) All of the above 4) Identified high risk areas that require alarm management include (circle all that apply) a) ICU b) OPS c) ED d) Labor & Delivery 5) Physiologic monitors, pulse oximetry, end tidal CO2, and ventilators are considered important alarm alerts to manage True False 6) Prior to placing electrodes on the patient, skin preparation would include all except a) Using mild soap and water to clean the skin's surface b) Using alcohol pads to clear the skin's surface c) Clipping excess hair from the electrode site d) Using gentle abrasion to the skin where the electrode is to be placed


Appendix J

Alarm Management Module Quiz Page 2

7) Electrodes should not be place directly over a bony or muscle areas on the body True False 8) When applying ECG leads, the brown (V1) lead is placed a) Left of the sternal border at the 4th intercostal space (ICS) b) Right of the sternal border at the 4th intercostal space (ICS) c) Left of the sternal border at the 5th intercostal space (ICS) d) Right of the sternal border at the 5th intercostal space (ICS) 9) How often is it recommended that ECG pads be changed a) Once a day b) Every 2 days c) Every 3 days d) Only as needed 10) Changing electrodes daily may decrease false alarms by a) 25 % b) 37% c) 46% d) 47% 11) Charting for daily electrode changes is done in the Cardiac Rhythm section of the IView Flowsheet True False


Appendix K

Staff Recognition Sign


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge

Co

mp

lia

nt

wit

h E

du

ca

tio

n

Correct Lead Placement and Electrode Correct Lead Placement and Electrode Correct Lead Placement and Electrode Correct Lead Placement and Electrode


Appendix L

Correct Lead Placement and Electrode Correct Lead Placement and Electrode Correct Lead Placement and Electrode Correct Lead Placement and Electrode ChangeChangeChangeChange

Correct Lead Placement

Daily Electrode Change

38

Correct Lead Placement

Daily Electrode Change


0

100

200

300

400

500

600

700

800

900

1000

Number

of

Alarms


Appendix M

Chart Title

Bed Alarms

Yellow Alarms

39

Bed Alarms

Yellow Alarms


Appendix N

Cerner Change Request Mock Up

alarm management: electrocardiographic lead management

Documents